19 & 10-C Archives - HR Letter Formats

EPF Form 19 & 10-C Format

I have Attached EPF Form 19 & 10-C Format

Mobile: 98427 98427

Serial No.

For Office Use Only

In Words No.

Form No.10 C (E.P.S)

[Withdrawl Benefit]

EMPLOYEES’ PENSION SCHEME, 1995

FORM TO BE USED BY A MEMBER OF THE EMPLOYEES’ PENSION SCHEME,1995

FOR CLAIMING WITHDRAWL BENEFIT / SCHEME CERTIFICATE

1. a) Name of the member (In Block Letters)

ABC

b) Name of the Claimant (s)

ABC

2. Date of Birth

3. a) Father’s Name

XYZ

b) Husband’s Name (If applicable)

NOT APPLICABLE

4. Name & Address of the Establishment

ABC COMPANY INDIA PVT LTD.,

in which, the member was last employed

X-18, 6th Cross Cut Road, Perundurai, Erode – 52.

5. Code No. & Account No.

Region/SRO Code

Estt.Code No.

A/c No.

XXXXX

YYY

6. Reason for leaving service

CESSATION (SHORT SERVICE)

& Date of leaving

1-Feb-2012

7. Full Postal Address (In Block Letters)

Shri/Smt/Kumari

ABC

S/o, W/o, D/o

XYZ

1/12 – ANTI VALASA, MAKKUVA POST & TALUK,

Vizianagaram, A.P.. PIN: 535 547

8. Are you willing to accept Scheme

(a)

(b)

Certificate in lieu of withdrawl benefits

Yes

√

9. Particulars of Family (Spouse & Children & Nominee)

Name

Date of Birth

Relationship with member

Name of guardian of minor

(a) Family Members

PAPARAO

1966

FATHER

–

PARVATHI

1976

MOTHER

–

(b) Nominee

PAPARAO

1966

FATHER

–

PARVATHI

1976

MOTHER

–

10. In case of death of member after attaining the age of 58 years without filing the claim :-

(a) Date of death of the member :

Not Applicable

(b) Name of the Claimant(s) / and relationship with the members :

Not Applicable

11. MODE FOR REMITTANCE [PUT A TICK IN THE BOX AGAINST THE ONE OPTED]

(a) By postal money order at my cost to address given against item No.7

(b) Account payee cheque sent direct for credit to my SB A/c (Scheduled Bank) under intimation

to me

√

S.B Account No.

Name of the Bank (In Block Letters)

STATE BANK OF INDIA

Branch (In Block Letters)

PERUNDURAI

Full Address of the Bank

KOVAI MAIN

(In Block Letters)

PERUNDURAI

12. Are you availing pension under EPS-95? :

If so indicate:

PPO No.

By whom issued

Certified THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE

Signature or left Hand

Thumb Impression of the

Date: 02-04-2012

Member / Claimant(s)

ADVANCE STAMPED RECEIPT

[To be furnished only in case of (b) above]

Received a sum of Rs._________________ (Rupees__________________________________________________

only from the Regional Provident Fund Commissioner / Officer-in charge of Sub-Regional

Office _____________________________

by deposit in my savings bank A/c towards the settlement of my Pension Fund Accounts

(The space should be left blank which shall be filled by Regional Provident Fund Commissioner / Officer-in-

charge)

Signature or left thumb impression of the member on the stamp

Rs.1/-
Revenue
Stamp

Certified that the particulars of the member given are correct and the member has signed / thumb impressed

before me.

The details of wages and period of non-contributory service of the member are as under :-

Form 3A/7 (EPS) enclosed for the period for which it was not sent to Employee’s Provident Fund Office)

Wages (Basic+DA) as on 15.11.1995 (if applicable) :

Not Applicable

Wages as on the date of exit :

Rs.100.00 per day

Period of non contributory Service

Year / Month

No. of Days

2011 / 10

17.0

2011 / 11

4.0

2011 / 12

2.0

2012 / 01

19.0

TOTAL

42.0

Signature of Employer/

Date: 04-02-2012

authorised official

(FOR THE USE OF COMMISSIONER’S OFFICE)

(Under Rs.____________________________________________________________________________________

P.I No._________________________________ M.O./Cheque

Passed for payment Rs.___________________________ (in words)___________________

M.O Commission (if any)_________________ Net amount to be paid by M.O_______________________________

____________________________________________________________________________________________

towards withdrawl benefit.

D.H

S.S

A.A.O

(FOR USE IN CASH SECTION)

Paid by inclusion in cheque No._________________ Dt_________________vide cash Book(Bank) Account

No. 10 Debit item No.__________________________

D.H

S.S

AC(A/cs)

For issue if S.S;. IDS is enclosed.

D.H

S.S

A.A.O/APFC (A/cs)

(FOR USE IN PENSION SECTION)

Scheme Certificate bearing the Control No._________________ Issued on _______________________and

entered in the Scheme Certificate Control Register-

D.H

S.S

A.A.O

APFC (PENSION)

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